Mechanisms and management of prothrombotic state in COVID-19 disease

The novel severe acute respiratory syndrome viral disease outbreak due to SARS-CoV-2 is a rapidly evolving disease and represents one of the greatest medical challenges in recent times. It is believed that SARS-CoV-2 has migrated from bats to an intermediate host and then to humans. This article aims at the mechanism and management of prothrombotic state in COVID-19 positive patients. We tried to present how the SARS-CoV-2 virus can induce thromboembolic events and the incidence of these thromboembolic events. We also tried to depict anticoagulation management in these patients as well as postdischarge plan and follow-up. Invasion of type 2 pneumocytes by the SARS-CoV-2 virus is critical in the course of illness because it results in activation of immune cells leading to elevation of cytokines. The subsequent activation of T cells and macrophages infiltrates the infected myocardial cells causing direct myocardiocyte toxicity and development of arrhythmia. Hypoxia or hypotension during the clinical course causes a mismatch between myocyte oxygen supply and workload demand resulting in cardiac distress. SARS-CoV-2 affects endothelial cells and pericytes that lead to severe micro and macrovascular dysfunction, and together with oxygen supply-demand mismatch, immune hyperresponsivity can potentially cause destabilization and plaque rupture causing acute coronary syndromes. Other mechanisms of injury include myocarditis, pericarditis, stress cardiomyopathy, vasculitis, and DIC (Disseminated intravascular coagulation)/microthrombi. SARS-CoV-2 enters the cells by the Spike protein S whose surface unit, S1, binds to the ACE2 receptor on the host cell. The type II transmembrane serine proteases TMPRSS2 and histone acetyltransferases (HAT) are host cell proteases that are recruited by the virus to cleave ACE2 surface protein S which facilitates the viral entry. Therefore, TMPRSS2 and HAT could be targeted for potential drugs against SARS-CoV-2. SARS-CoV-2 uses an RNA-dependent RNA polymerase for proliferation, which is targeted by remdesivir that is currently approved for emergency use by Food and Drug Administration (FDA). We need to adopt a multifaceted approach when combating SARS-CoV-2 because it presents several challenges including medical, psychological, socioeconomic, and ethical. COVID-19 is the biggest calamity during the 21st century, we need to have a keen understanding of its pathophysiology and clinical implications for the development of preventive measures and therapeutic modalities.

Obesity is a risk factor for epidural lipomatosis: a meta-analysis

PURPOSE

The purpose of this meta-analysis was to summarize the evidence of associations between obesity factors and spinal epidural lipomatosis (SEL) and to evaluate the strength and validity of these associations.

METHODS

Electronic databases such as Wiley Online Library, PubMed, Embase, Cochrane Library were searched and manual retrieval of references, the time limit was from the establishment of the database to May 2020. Methodological quality evaluations of the included studies were assessed using the bias risk assessment tool recommended by the Cochrane Guidelines. The RevMan 5.3 software was used for meta-analysis.

RESULTS

Finally, seven studies were included for meta-analysis, all of which were observational studies with mixed bias risk. These studies involved 807 patients, with an average age of 64 to 73.6 years, and 59.4 percent of the participants were male. The sample sizes for the included studies ranged from 28 to 288. The results of meta-analysis showed that high body mass index (BMI) was one of the factors affecting SEL (P < 0.01, MD 1.37, 95% CI [0.81, 1.92]). All reviews had a high risk of bias, and the most common source of bias was that there was no strict unified case diagnosis standard between researches, and some studies (four items) did not clearly describe the confounders that they controlled.

CONCLUSIONS

We suggest that physicians should consider high BMI as a factor leading to SEL, and to control body weight actively should be considered as the preferred treatment strategy before surgical intervention is conducted.

The effect of twelve weeks of treatment with ezetimibe on HDV RNA level in patients with chronic hepatitis D

BACKGROUND/AIMS

Sodium taurocholate co-transporting polypeptide (NTCP) is the receptor for the hepatitis B virus (HBV) and hepatitis D virus (HDV) entry into hepatocytes. Ezetimibe is a cholesterol-lowering drug that possesses the pharmacophore features to inhibit NTCP. This study evaluates the efficacy of ezetimibe in patients with chronic HDV infection in a nonrandomized trial.

MATERIALS AND METHODS

This proof of concept phase 2 trial evaluated the efficacy and safety of ezetimibe 10 mg daily in (interferon treatment-experienced or interferon ineligible) patients with chronic hepatitis D (CHD). Forty-four patients with CHD were recruited, 38 male and 6 female patients, mean age 35.2±8.7 (range 19-64). Fifteen (34%) patients were on concomitant nucleoside therapy, and cirrhosis was present in 14 subjects. The primary therapeutic endpoint was a decline in HDV RNA at one log or more from the baseline at week 12.

RESULTS

The mean HDV RNA level was 5.4±1.3 log10 IU/mL. HBeAg was non-reactive in 43 (98%). HBV DNA was undetectable in 28 (64%). One patient stopped treatment at week 4, and one patient did not follow-up. One log or more reduction in the HDV RNA levels was observed in 18/44 (41%) patients. No log reduction occurred in 16 patients, and 8 experienced a log increase. No adverse effects from the concomitant nucleoside analogue use or clinical cirrhosis were observed. The drug exhibited a positive safety profile.

CONCLUSION

Treatment of CHD patients with ezetimibe resulted in a one log reduction of viral load in 43% (18/42) of the patients who completed the 12 weeks of therapy.

Biomarkers in Acute Heart Failure Syndromes: An Update

Heart failure is one of the leading healthcare problems in the world. Clinical data lacks sensitivity and specificity in the diagnosis of heart failure. Laboratory biomarkers are a non-invasive method of assessing suspected decompensated heart failure. Biomarkers such as natriuretic peptides have shown promising results in the management of heart failure. The literature does not provide comprehensive guidance in the utilization of biomarkers in the setting of acute heart failure syndrome. Many conditions that manifest with similar pathophysiology as acute heart failure syndrome may demonstrate positive biomarkers. The following is a review of biomarkers in heart failure, enlightening their role in diagnosis, prognosis and management of heart failure.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

The pedicled submental flap in facial reconstruction

Submental flap (SF) is a reconstructive technique that can be utilised for reconstruction of medium to large oral cavity defects, head and neck cancer, and pharyngocutaneous fistula. The submental artery island flap is pedicled on the submental artery and veins. The vascular pedicle has a length of up to 8cm. If it is further dissected to its origin from the facial artery, the pedicle can be lengthened by an additional 1-2cm to reach the lateral canthus and zygomatic arch. The use of SF for the reconstruction of head and neck defects has re-emerged over the past decade due to various reasons. We present a series of four case reports of head and neck cancers including a basal cell carcinoma, squamous cell carcinoma, and Merkel tumour, where the SF technique was used to successfully reconstruct the resultant facial defect. The advantages and disadvantages of the SF are discussed with a brief literature review.

Myocarditis and Drug Rash With Eosinophilia and Systemic Symptoms Syndrome: A Deadly Combination

DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) is a severe delayed type IV hypersensitivity drug reaction by T helper cell 2 (Th2) and Interleukin 5 (IL-5) resulting in activation of eosinophils. It is mostly reported with antiepileptic drugs (AEDs), antibiotics, and allopurinol. Here, we present the second case of myocarditis secondary to DRESS syndrome caused by amoxicillin. Most of the case reports present with cross-reactivity among the anticonvulsants and beta-lactams, which is also rarely been reported. Amoxicillin could reactivate human herpesvirus 6 (HHV 6) and Epstein-Barr virus (EBV) with a presentation similar to DRESS syndrome, but our patient was neither taking the anticonvulsants nor have any viral infection in the recent past. His RegiSCAR score was 6, consistent with definite DRESS syndrome. Management includes identification and prompt withdrawal of the offending drug and supportive care for patients without severe organ involvement and systemic corticosteroids for patients with severe organ involvement.

Hepatoprotective activity of silymarin encapsulation against hepatic damage in albino rats

Liver fibrosis occurs due to liver injuries and toxins. Silymarin (SMR) extracted by the milk thistle seeds, is widely used such as herbal drug for its hepatoprotective properties. The purpose of this study to assess the properties of an optimized dose of encapsulated crude SMR on antidiabetic activity and liver fibrosis induced by paracetamol in male albino rat. Hepatic fibrosis was assessed by measuring liver enzymes. Results revealed that the consumption of encapsulated SMR, can effectively affluence the target and avoid the degradation of bioactive compound. Body weight of animal also significantly increased in each group during all the period. According to our optimized study, the long-term induction of SMR (300 mg/kg) significantly amplified survival time of rats with paracetamol induced hepatic injuries. The changes of liver fibrosis and the significant increase of hepatic enzyme biomarkers were also observed. In conclusion, the results suggest that SMR acts as a hepatoprotective agent by inhibiting the fibrogenisis and apoptosis in liver, as well as insulin resistance.

The subclinical hypothyroid state might predict 30-day readmission in patients admitted with acute heart failure syndrome and reduced left ventricular ejection fraction

INTRODUCTION

Thyroid hormone (TH) has an essential role on the functional capability of cardiac muscle with its gene modulation and induction of vasodilatory effects. There is considerable evidence to suggest the role of TH in patients with acute coronary syndrome, but less is known about its prognostic role in heart failure (HF) patients. We aim to evaluate the association between subclinical hypothyroid state (SCHS) and event rates including 30-day all-cause and HF readmission in patients with an index hospitalization for acute HF syndrome (AHFS).

METHODOLOGY

A retrospective chart review analysis of 2335 patients admitted with the diagnosis of AHFS between 1 January 2007 and 31 December 2017 was conducted. SCHS was defined as thyroid-stimulating hormone (TSH) level >4.50 mIU/L with a normal thyroxine (T₄) level. Patients with pre-existing thyroid disease or receiving thyroid replacement therapy were excluded. HF with preserved ejection fraction (HFpEF) was defined as left ventricular ejection fraction (LVEF) >40% and HF with reduced ejection fraction (HFrEF) was defined as having LVEF ⩽40%. Percentage of 30-day, 3-month and 6-month all-cause readmission and mortality rates were calculated in both cohorts of AHFS (HFpEF and HFrEF) with and without SCHS.

RESULTS

The mean age of the 2335 AHFS population was 65 (±14.8) years. Of the 2335 patients admitted with AHFS, 1228 (52.6%) patients were found to have HFrEF and 1107 (47.4%) with HFpEF. There were 170 (7.3%) patients with AHFS found to have SCHS. There were more males than females (54% versus 46%). The percentage of hospital readmission within 30 days was higher for patients with SCHS compared with those without SCHS in the HFrEF group (42% versus 30%, p = 0.001). Hospital readmission within 30 days for patients with SCHS compared with those without SCHS in the HFpEF group did not differ (36.5% versus 31%, p = 0.47). Additionally, all-cause mortality was higher among patients with SCHS compared with patients without SCHS in the HFrEF group (18.7% versus 7.0%, p < 0.001). All-cause mortality was found similar in both arms of the HFpEF group (9.5% versus 7.7%, p = 0.73).

CONCLUSION

During an index hospital admission for AHFS, SCHS was an independent predictor of readmission in 30 days in patients with HFrEF but not in patients with HFpEF. Additionally, it was related to adverse outcome such as all-cause mortality in HFrEF patients but not in HFpEF patients. Further studies regarding the concept of tissue thyroid and the potential for a therapeutic target are warranted.

Effectiveness Of Sofosbuvir And Ribavirin In Hepatitis C Genotype 3 Relapsers

BACKGROUND

Combination of DAAs, Sofosbuvir and Ribavirin has been known as an effective treatment for HCV genotype 3. The aim of our study is to assess the efficacy of Sofosbuvir and Ribavirin in relapsed HCV genotype 3 patients.

METHODS

A cross-sectional retrospective analysis of hospital records between January 2015 and December 2016. Data was taken of only those patients who were followed for one year. A total of 193 cases were included in this study who were HCV genotype 3 relapsers and out of these 28 patients failed to be followed. Data was entered and analysed in IBM SPSS software package 23.

RESULTS

Out of the total 193 cases, 74.1% of cases achieved RVR at 4 weeks of therapy. ETR was achieved by 91.2% cases, while 8.8% of cases were non-responders. There was statistical significance in gender achieving ETR with a p-value of .008. 84.5% of cases achieved SVR-12. Statistical significance was noted between haemoglobin levels at presentation and 4 weeks follow-up with a p-value <0.005, and also between 4 weeks and 12 weeks follow-up with a p-value <0.005. Statistical significance was also found between age and PCR at 4 weeks (p-value of .002), age and PCR at 24 weeks (p-value of .051) and between ALT levels and PCR at 4, 12 and 24 weeks follow up (p-value <0.005). At 1-year follow-up, 79.3% of cases achieved a negative PCR, 28 patients failed to be followed, 6.2% of cases had a positive PCR. 5.5% of cases of the total 163 SVR cases had a relapse at 1 year.

CONCLUSIONS

HCV genotype 3 patients can benefit from Sofosbuvir and Ribavirin. With the SVR of more than 80%, this combination is cost-effective and safe. Treatment duration should be dependent on RVR and viral load at 4 weeks follow-up.

A Rare Presentation of Angina and Arrhythmia in Absent Left Main Coronary Artery

Coronary artery anomalies (CAAs) are congenital disorders with multiple variations in the number, shape, and location of the Ostia of the coronary arterial system. The congenitally absent left main coronary artery (LMCA) is a rare anomaly that can present with benign or fatal complications ahead in life. Diagnosis and management of CAAs are sometimes challenging in low-risk patients.

We present a unique case report of a 69-year-old Hispanic female who presented to the hospital with exercise-induced arrhythmia and angina symptoms. The patient complained of several episodes of chest pain, dizziness, and palpitations for a duration of two months. Electrocardiogram (EKG) and nuclear stress tests were equivocal. The angiogram revealed the separate origin of the left anterior descending artery (LAD) and left circumflex coronary artery (LCX) from the left coronary sinus. This anomaly should be considered in differentials when evaluating patients with angina symptoms.

Congenital absence of LMCA is a rare condition that remains asymptomatic in the majority of the cases. It can present with exertional chest pain, palpitations, syncope, and sudden cardiac death (SCD). Occurrences of angina and arrhythmia should be carefully evaluated, and symptoms should be followed up closely. A coronary angiogram and electrophysiological testing can assist in the diagnosis.

Hemorrhagic Pericardial Effusion Leading to Cardiac Tamponade: A Rare Initial Presentation of Adenocarcinoma of the Lung

Malignancy associated pericardial effusion is a serious condition and testifies to poor prognosis. Cardiac tamponade can be the first presentation of underlying adenocarcinoma of the lung. We present a 78-year-old female with no known history of any malignancy, who presented with symptoms of abdominal and respiratory pathology. The physical exam findings were significant for a possible cardiac tamponade. Computed tomography (CT) of the abdomen and chest confirmed moderate bilateral pleural effusions, large pericardial effusion, left upper lobe mass, possible lymphangitic spread of carcinoma in the left lung, and adenopathy in the mediastinum. The echocardiography findings further confirmed tamponade. Cardiology and pulmonary medicine were taken on board for a possible malignancy associated pleural effusion leading to cardiac tamponade. Pericardial fluid analysis showed atypical cells suggestive of malignancy. Transbronchial biopsy confirmed moderately differentiated invasive adenocarcinoma. Positron emission tomography (PET) scan revealed metastatic spread to the mediastinum and right hilum with possible pleural metastatic disease seen posteriorly in the left hemithorax. The patient was discharged home with oncology follow up for chemotherapy.

Impact of morphine treatment with and without metoclopramide co-administration on myocardial and microvascular injury in acute myocardial infarction: insights from a randomized trial

Background

Intravenous morphine administration in patients with acute myocardial infarction (AMI) can adversely affect platelet inhibition induced by P2Y12 receptor antagonists, potentially resulting in an increased risk of adverse clinical events. In contrast, some evidence suggests that opioid agonists may have cardioprotective effects on the myocardium. Currently available data in this regard are, however, sparse, inconsistent, and methodologically limited.

Purpose

The aim of this study was to investigate the impact of morphine with or without metoclopramide (MCP) co-administration on myocardial and microvascular injury after AMI assessed by cardiac magnetic resonance (CMR).

Methods

This prospective, randomized, single-center study assigned 138 patients with AMI in a 1:1:1 ratio to (a) ticagrelor 180 mg plus intravenous morphine 5 mg (morphine group); (b) ticagrelor 180 mg plus intravenous morphine 5 mg and MCP 10 mg (morphine + MCP group); or (c) ticagrelor 180 mg plus intravenous placebo (control group). Study drugs were administered before primary percutaneous coronary intervention. CMR was performed in 101 patients on day 1–4 after the index event to assess infarct size, microvascular obstruction, and left ventricular ejection fraction.

Results

Infarct size was significantly smaller in the morphine only group as compared to controls (15.5%LV [IQR 5.0 to 21.4%LV] vs. 17.9%LV [IQR 12.3 to 32.9%LV]; p=0.047). Furthermore, the number of patients with microvascular obstruction was significantly lower after morphine administration (10/36 [28%] versus 21/39 [54%]; p=0.022) and the extent of microvascular obstruction was smaller (0%LV [0 to 1.40%LV] versus 0.74%LV [0 to 3.10%LV]; p=0.037). In multivariable regression analysis, morphine administration was independently associated with a reduced risk for the occurrence of microvascular obstruction (odds ratio 0.37; 95% confidence interval 0.14 to 0.93; p=0.035). Left ventricular ejection fraction did not differ significantly between the morphine and the control group (p=0.970) and there was no significant difference in left ventricular ejection fraction (p=0.790), infarct size (p=0.491), and extent (p=0.753) or presence (p=0.914) of microvascular obstruction when comparing the morphine + MCP group to the control group.

Conclusions

In this randomized study, intravenous administration of morphine prior to primary percutaneous coronary intervention resulted in a significant reduction of myocardial and microvascular damage following AMI. This potential cardioprotective effect of morphine requires further evaluation in well-designed future trials with clinical endpoints.

Funding Acknowledgement

Type of funding source: None

Miller Fisher Variant of Guillain-Barré Syndrome: A Great Masquerader

Guillain-Barré Syndrome (GBS) is an acquired degenerative, demyelinating neurological disorder classically characterized by progressive, symmetrical ascending paralysis. Often associated to occur after a viral illness, most commonly an upper respiratory infection (URI), followed by gastrointestinal illnesses. Here we present a case of Miller Fisher syndrome (MFS) which is a rare variant of GBS. MFS presents with a triad of ataxia, areflexia, and opthalmoplegia. MFS is a clinical diagnosis but can be confirmed serologically with positive anti-ganglioside antibodies. 

Galactin-3 and soluble ST2 as complementary tools to cardiac MRI for sudden cardiac death risk stratification in heart failure: A review

Heart failure (HF) is recognized as one of the leading causes of morbidity and mortality worldwide. Every year about 500,000 new cases of HF are diagnosed in the United States. The predominant etiology of death in HF patients include sudden cardiac death (SCD) and pump failure. Prediction of mode of death may help in devising management decisions. In patients with HF, the presence of myocardial fibrosis has been a known risk factor for SCD and thus it could be used as a criterion in risk stratification for SCD. However, the underlying pathophysiology of SCD is uncertain and controversial, which makes it necessary to develop newer tools to enhance SCD risk stratification. The newer tools should be innovative enough either to complement or to replace the currently available tools. In this scoping review, we highlighted the utilization of novel biomarkers galectin-3 (gal-3) and soluble ST2 (sST2) and discussed that how they might complement currently available tools such as, cardiac MRI (CMR) for SCD risk stratification in HF patients.

Insights on toxin genotyping, virulence, antibiogram profiling, biofilm formation and efficacy of disinfectants on biofilms of Clostridium perfringens isolated from poultry, animals and humans

AIMS

This study aimed to determine the toxin genotypes, virulence determinants and antibiogram of Clostridium perfringens isolated from poultry, animals and humans. Biofilm formation and the efficacy of disinfectants on C. perfringens biofilms were studied.

METHODS AND RESULTS

Thirty C. perfringens isolates (20 clinical and 10 from chicken carcasses) were genotyped by PCR and all isolates were genotype A (cpa+). The overall prevalence of cpe, cpb2, netB and tpeL virulence genes was 6·7, 56·7, 56·7 and 36·7% respectively. Twenty-one isolates (70%) were multidrug-resistant, 8 (26·7%) were extensive drug-resistant and one isolate (3·3%) was pan drug-resistant. The average multiple antibiotic resistance index was 0·7. Biofilms were produced by 63·3% of C. perfringens isolates and categorized as weak (36·7%), moderate (16·7%) and strong (10%). Sodium hypochlorite caused significant reduction in C. perfringens biofilms (P < 0·0001).

CONCLUSIONS

All C. perfringens strains in this study were type A, resistant to multiple antibiotics and most of them were biofilm producers. Sodium hypochlorite showed higher efficacy in reducing C. perfringens biofilms.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study reported the efficacy of disinfectants in reducing C. perfringens biofilms of economic and public health concern and recommends application on surfaces in farms, food processing plants and slaughterhouses.

Effect of follicle size on oocytes recovery rate, quality, and in-vitro developmental competence in Bos indicus cows

The objective of the present study was to determine the effect of follicle size on recovery rate, quality, and in-vitro developmental competence of oocytes in Bos indicus cows. The ovaries (n = 507) of Bos indicus cows having age of 5-8 years, with mixed parity, BCS 2.75 ± 0.25, and clinically normal reproductive tracts were collected from the local abattoir. The follicles on the ovaries were divided into two groups based upon their size; 1) ≥6 mm diameter, and 2) <6 mm diameter. After initial evaluation of quality of the oocytes, the COCs were in vitro matured, fertilized, and cultured to determine the in vitro developmental competence. The oocyte recovery, quality, maturation, cleavage, 4-cell, 8-cell, and 16-cell stages were analyzed using PROC GLIMMIX procedure of SAS. However, the number of oocytes recovered per ovary was analyzed using MIXED procedure of SAS. Results revealed that the recovery of oocytes (LSM ± SEM) derived from the follicles having size <6 mm per ovary was greater (1.02 vs. 3.14 ± 0.13; P < 0. 0001). However, the percentage (n/n) recovery [69.8 (474/679) vs. 62.7% (1454/2320); P = 0.01] and grade I_+_II oocytes [68.4 (324/474) vs. 57.9% (842/1454); P < 0.0001] was greater in ≥6 mm as compared with <6 mm group, respectively. However, maturation rate did not differ [92.9 (288/310) vs. 92.2% (296/321); P = 0.98] between the groups. In contrast, cleavage rate [58.1 (180/310) vs. 47.4% (152/321); P = 0.01], the 4-cell [34.5 (107/310) vs. 18.7% (60/321); P = 0.0003], 8-cell [15.5 (48/310) vs. 7.8% (25/321); P = 0.008], and 16-cell [8.7 (27/310) vs. 2.1% (7/321); P = 0.004] stage embryos were greater in ≥6 mm group. It can be concluded that oocytes derived from follicle ≥6 mm have better in vitro developmental competence based on embryonic conversion in Bos indicus cows.

Does Extended Use of Clopidogrel-Based Dual Anti-Platelet Therapy Increase the Risk of Gastrointestinal Bleeding?

Background

Clopidogrel-based dual anti-platelet therapy (CDAPT) has shown significant benefits in the management of coronary artery disease (CAD), up to 1-year duration. Gastrointestinal bleeding (GIB) is one of the limiting factors for prolonged use of CDAPT.

Methods

We identified all patients taking CDAPT from our ambulatory clinics. Demographic, clinical, laboratory and pharmacological data were abstracted. American Heart Association (AHA) guidelines were used to determine the duration of CDAPT therapy. The study population was divided into two groups based on the duration of therapy. Individuals who received CDAPT more than 12 months were deemed as extended use.

Results

A total of 351 patients with CAD were taking CDAPT. Majority of patients (276/351, 79%) were taking CDAPT beyond 1 year. There were no differences in baseline characteristics between the two groups. There was no significant difference in the incidence of GIB between the two groups. However, in subgroup analysis, there was a significant difference in the incidence of GIB in men. Men who were taking CDAPT beyond 12 months had almost three times higher incidence of GIB compared to those who were taking less than 12 months (25% vs. 8%, P = 0.04). The excess GIB in men prevailed despite adjusting for non-steroidal anti-inflammatory drugs (NSAIDs) or direct oral anticoagulant (DOAC) use.

Conclusions

We found that a majority of patients were taking CDAPT beyond the recommended duration. We observed that men taking CDAPT for an extended duration had a three times higher incidence of GIB. It would be reasonable for physicians to be aware of the higher risk of GIB in men and carefully assess the risks and benefits of extended use of CDAPT.

Meta-analysis to determine effects of treatment with FSH when there is progestin-priming on in-vitro embryo production using ovum pick-up in Bos taurus cows

Treatments with follicle stimulating hormone (FSH) to enhance ovarian follicular development before ovum pick-up (OPU) are important for improving in-vitro embryo production (IVEP) procedures in cows, however, their procedural efficacy needs to be evaluated. The objective of the present study was to use meta-analytic methods to determine the effects of FSH treatments prior to OPU when there is progestin-priming on ovarian functions and IVEP in parous Bos taurus cows (n = 243). The literature was systematically reviewed and data from eight experiments, with 23 treatment means including 448 OPU sessions, were used for analyses. All eight experiments included a group of cows in which there was no FSH treatment (CON), and treatment with FSH before OPU to conduct IVEP. Mixed models were fitted using MIXED and GLIMMIX procedures of SAS. Additionally, classical meta-analytical statistics were also fitted using METAN and METAREG procedures of STATA. Models included fixed effects of treatment (i.e., CON and FSH) and random effect of the experiment, and data were weighted using the inverse of the SEM squared to account for precision of each experiment. Number of medium sized follicles, quality of oocytes, and transferable embryos were greater (P < 0.05) in FSH-treated as compared with cows of the CON group, without indications of publication bias or heterogeneity of data. Taken together, the results from the present study lead to the recommendation for treatments with FSH prior to OPU for IVEP when there was progestin-priming imposed to obtain a large number of transferable embryos for economic sustainability of commercial embryo transfer programs in parous non-lactating Bos taurus cows.

A very severe case of rhinophyma requiring a three-stage reconstruction with a forehead flap

Rhinophyma is a skin condition that affects the nose. It is often characterised by a large, red, bulbous nose. It can have a physical, psychological and social impact on the patient. Management options include conservative medical therapy such as retinoids or surgical excision followed by reconstruction as required. The reconstruction options can range from a dermal substitute full-thickness skin graft to local flaps, depending on the wound bed. We present a severe case of rhinophyma that required a complex reconstruction with a three-stage forehead flap because of the mass effect and the wound that resulted from the surgical excision of an extremely large and troublesome rhinophyma.

Effect of photoperiodicity and methods of follicular wave emergence on follicle turn-over, recovery and quality of oocytes, and early in-vitro developmental competence of embryos using ovum pick-up in Nili-Ravi buffaloes: Preliminary evidence

The objectives of the present study were to evaluate the effects of photoperiodicity, gauge (G) of ovum pick-up (OPU) needle, and two methods of follicular wave emergence on follicular turn-over, oocyte recovery (OR), quality of the oocytes (OQ), and early in-vitro developmental competence of embryos in Nili-Ravi buffaloes (n = 20). In 1^st experiment, buffaloes (n = 12; 4 buffaloes/season) were randomly assigned to optimize the OPU's (n) either with 17 G or 18 G needle in one of the following seasons: 1) peak breeding season (PBS; Sep-Nov; n = 31), 2) transition breeding season (TBS; Dec-Feb; n = 32), and 3) low breeding season (LBS; Apr-June; n = 32). During 2^nd experiment, buffaloes (n = 8) were enrolled randomly in a 2 × 2 cross-over design to compare the two methods of wave emergence either using follicular ablation (FA; n = 4), or synchronization protocol (CIDR-EB; n = 4) during PBS. In FA method, the ovarian follicles were aspirated (week -1), and subsequently repeated OPU's (n = 55) were performed for 7 weeks. However, in CIDR-EB synchronized buffaloes, a progesterone device (CIDR) was inserted in the anterior vagina and a single dose of estradiol benzoate (2 mg) and prostaglandin (150 μg) were administered i.m. on d 1. The CIDR was removed on d 7 and repeated OPU's (n = 56) were performed. In both experiments, a 7-d resting period was provided between each OPU session. Data on the follicular turn-over, OR, OQ, and early stages of embryonic development were analyzed with mixed models using the PROC MIXED and GLIMMIX procedures of SAS. Results revealed that the number of medium sized follicles (LSM ± SEM) and rate of OR (%) were greater (P < 0.05) during PBS (2.76 ± 0.40; 61%) and TBS (1.73 ± 0.30; 54%) as compared to LBS (0.68 ± 0.30; 31%) in buffaloes, respectively. The OR rate was also greater (P < 0.05) using 17 G as opposed to 18 G needle (62% vs. 35%), however, there was no effect (P > 0.05) of season and G of needle on OQ in buffaloes. In experiment 2, the number of small (3.50 ± 0.63 vs.2.69 ± 0.60) sized follicles was higher (P < 0.05) in FA, whereas, medium (1.13 ± 0.45 vs. 1.59 ± 0.45) sized follicles were greater (P < 0.05) in CIDR-EB synchronized buffaloes. The OR rate (67% vs. 53%), and OQ (Grade I_+_II; 15% vs. 16% and Grade III_+_IV; 85% vs. 84%), remained similar (P > 0.05) in FA and CIDR-EB treated buffaloes, respectively. Similarly, rates of in-vitro maturation (66% vs. 59%), cleavage (42% vs. 53%), 4-cell (27% vs. 32%), 8-cell staged embryos (23% vs. 25%), and morula (13% vs. 8%) did not differ (P > 0.05) between FA and CIDR-EB methods of follicular wave emergence, respectively. Taken together, it is concluded that peak or transition breeding seasons are suitable to perform OPU using 17 G needle for maximum follicular turn-over, and OR in buffaloes. However, the two fundamental methods of synchronization of wave emergence resulted in similar efficiency for OPU derived in-vitro embryo production in Nili-Ravi buffaloes.

Acute Cytomegalovirus (CMV) Hepatitis in an Immunocompetent Adult

BACKGROUND Cytomegalovirus (CMV) is a member of Herpesviridae family with its name derived from the fact that it causes enlargement of the infected cell resulting in the characteristic inclusion bodies seen on microscopy. CMV virus has an incubation period of about 4 to 6 weeks. Symptoms of CMV infection vary and depend on factors including the age and immune status of the patient. It usually presents as asymptomatic infection in immunocompetent individuals whereas severe disease is usually seen in immunocompromised patients. Here we present a case of an immunocompetent patient who presented with acute CMV hepatitis. CASE REPORT A 35-year-old male with no significant prior medical history who presented to the Emergency Department with a 2-week history of low-grade fever. Acute CMV infection was diagnosed by positive CMV antibody and polymerase chain reaction (PCR) testing. The patient was treated with valganciclovir that resulted in rapid improvement in clinical status as well as normalization of the liver enzymes. CONCLUSIONS This article presents a rare case of immunocompetent young male with acute CMV hepatitis who responded favorably to antiviral therapy.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

P1438Predictors and clinical impact of bleeding events after left atrial appendage closure in patients with high risk or a history of bleeding

Background

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation and may be especially attractive in patients with high risk or a history of bleeding. However, data of clinical benefit and incidence of post-procedural bleeding in patients with both high risk of bleeding and ischemic cerebral stroke after LAAC are lacking.

Objectives

This study sought to identify predictors and the prognostic impact of post-LAAC bleeding in patients at high risk and/or history of bleeding in the direct oral anticoagulant therapy (DOAC) era.

Methods and results

We retrospectively enrolled a total of 195 patients (75 ± 8.7 years, 38% female, 47% with previous major bleeding, mean CHA2DS2-VASc score 4.3 ± 1.6 and mean HAS-BLED score 2.7 ± 1.1) undergoing endocardial (91%) or epicardial (9%) LAAC during a mean follow-up of 339 ± 319 days. Twenty-three (11.9%) patients developed procedure-unrelated bleeding events after a median of 147 (43, 362) days after LAAC, in 12/23 (52%) patients under single antiplatelet therapy (SAPT), 6/23 (26%) dual antiplatelet therapy (DAPT), 1/23 (4%)  DOAC, 1/23 (4%) VKA, 2/23 (9%) dual therapy (SAPT and DOAC/VKA) and 1/23 (4%) triple therapy (DAPT and DOAC/VKA). (Figure) Diabetes mellitus and previous major bleeding were identified as the independent predictors of post-LAAC bleeding (Odds ratio 2.65 [95% CI:1.04-6.73], p = 0.041, and 5.50 [95% confidence interval:1.72-17.5], p = 0.004). Post-LAAC bleeding was associated with all-cause death (9/23 [39%] vs 18/171 [11%], p = 0.001), but not ischemic stroke/TIA (1/23 [4%] vs 6/171 [4%], p = 0.593) nor device thrombus (2/23 [9%] vs 3/171 [2%], p = 0.108). Kaplan-Meier curve estimated that patients with post-LAAC bleeding had a worse mortality than those without post-LAAC bleeding (3-year mortality; 35.6% [95%CI; 11.6-61.0%] vs 68.7% [45.0-83.8], p = 0.029)

Conclusions

In AF patients with high bleeding risk or history of bleeding undergoing LAAC, bleeding events are common and may occur even after long-term duration after LAAC. Previous major bleeding history strongly predicts subsequent bleeding events following LAAC and is associated with unfavorable mortality. Further investigations are required to identify optimal post-procedural antithrombotic strategies for patients undergoing LAAC with previous major bleeding.

Abstract Figure. The association between time to bleeding

193 Effect of clinical metritis on oocyte recovery, oocyte quality, and early invitro developmental competence of embryos in Bos indicus dairy cattle

Unhygienic practices at the time of parturition or AI lead to uterine infections. The uterine infections ultimately result in genetic drain by culling the elite animals. The invivo developmental competence of embryos is compromised in clinically metritic animals. The genetic potential of problematic females could be harvested by invitro embryo production (IVEP). Therefore, the objective of the present study was to evaluate the effect of clinical metritis on oocyte recovery, oocyte quality, and early invitro developmental competence of embryos in Bos indicus dairy cattle. This experiment was carried out from December 2017 to April 2018. Ovaries were collected from a local abattoir (Bos indicus; 5- to 8-year-old dairy cattle, body condition score 2.75±0.25, mixed parity). These ovaries (n=982) were divided into two groups: (1) clinically metritic (n=184), and (2) healthy (n=798), based upon the presence or absence of pus in the uterine lumen. Oocytes were aspirated from follicles using an 18G needle attached to a 10-mL syringe. Cumulus-oocyte complexes (COCs) were categorized into A, B, C, and D grades based on the number of layers of cumulus cells and integrity of ooplasm. The oocytes of grades A and B were subsequently transferred in groups (10/group) in four-well plates containing 100-μL droplets. The droplets with oocytes were covered with prewarmed mineral oil and incubated for 24h at 38.5°C, 5% CO2, and 95% relative humidity. The oocytes were evaluated for IVM on the basis of cumulus expansion. Frozen semen was thawed and prepared using the sperm swim-up procedure for each group. Spermatozoa and oocytes were incubated together for a period of 18h. The presumptive zygotes were invitro cultured for 4 days in a CO2 incubator under similar culture conditions. The cleavage rate, 4-cell, and 8-cell stages were recorded on Days 2, 3, and 4 after the day of insemination, respectively. Data on oocyte recovery, oocyte quality, IVM, cleavage rate, and 4-cell and 8-cell stages were analysed by Chi-squared test using SPSS software (version 20; IBM Corp.) for Windows. Results demonstrated that recovery rate was lower (63.8% vs. 71.7%; P&lt;0.05) in clinically metritic compared with healthy cattle. Similarly, oocytes of grade A and B quality were lower (41.0% vs. 51.1%; P&lt;0.05), whereas those of C and D quality were higher (59.0% vs. 48.9%; P&lt;0.05) in clinically metritic compared with the healthy group. Moreover, 4-cell (38.2% vs. 54.8%) and 8-cell stage embryos (11.3% vs. 29.1%), were lower (P&lt;0.05) in the clinically metritic compared with the healthy group, respectively. However, maturation rate and cleavage rate did not differ (P&gt;0.05) between groups. In conclusion, metritis in slaughterhouse ovaries negatively affects oocyte recovery rate, oocyte quality, and early invitro developmental competence of embryos in Bos indicus dairy cattle.

Ranolazine Induced Bradycardia, Renal Failure, and Hyperkalemia: A BRASH Syndrome Variant

Ranolazine is a well-known antianginal drug, that was first licensed for use in the United States in 2006. It was objectively shown to improve exercise capacity and to lengthen the time to symptom onset in patients with coronary artery disease. The most commonly reported side effects of ranolazine include dizziness, headache, constipation, and nausea. Here, we describe a case of bradycardia, hyperkalemia, and acute renal injury in the setting of ranolazine use. Our patient is an 88-year-old female who presented with abdominal pain, nausea, and vomiting. Her medical comorbidities included hypertension, diabetes, CAD, heart failure with preserved ejection fraction, paroxysmal atrial fibrillation, hypothyroidism, and a history of cerebrovascular accident without any residual deficits. Her prescription regimen included amlodipine, furosemide, isosorbide mononitrate, levothyroxine, metformin, omeprazole, and ranolazine. Physical examination was remarkable for bradycardia and decreased breath sounds in the left lower lung field. Laboratory studies were significant for a serum potassium level of 6.8 mEq/L and a serum creatinine level of 1.6 mg/dL. She was given insulin with dextrose, sodium polystyrene, and calcium gluconate in addition to fluids. Her bradycardia and renal function worsened over the next 24 hours. Ranolazine was discontinued. Metabolic derangements were treated appropriately. After 48 hours from presentation, potassium and renal function returned to baseline and her heart rate improved to a range of 60-100 bpm. She was discharged with an outpatient cardiology follow-up. Ranolazine treatment was not continued upon discharge. In summary, our case illustrates an association between ranolazine and renal failure induced hyperkalemia, leading to conduction delays in the myocardium. Though further studies are warranted, we suspect that this is a variant of the recently described BRASH syndrome. We propose that in cases such as ours, along with treatment of the hyperkalemia, medication review and removal of any offending agent should be considered.

Photoperiodic stress induces genotype-specific shift in DNA methylation in Tartary buckwheat

Tartary buckwheat, known for its rich source of health beneficial secondary metabolites, is cultivated in many areas of the world. Among different environmental factors, photoperiod strongly influence its growth, flowering time, and ultimately the yield. In this context, epigenetics could contribute significantly in the regulation of plant response against changing environment. Therefore, with the aim to study the involvement of DNA methylation in photoperiod mediated plant response, genome-wide DNA methylation analysis was performed in two accessions (A1 and A2) of Tartary buckwheat using three photoperiodic treatments, i.e., 10-hr light/day (T1), 12-hr light/day (T2), and 14-hr light/day (T3). Flowering time and plant fresh weight data revealed that accessions A1 and A2 prefer T1 and T2 treatments, respectively. Total DNA methylation ratio increased with the increase in photoperiod in accession A1 but decreased under same conditions in accession A2. Full methylation increased significantly while intensive decrease in hemimethylation was noted from T2 to T3 in A1, whereas full methylation strongly increased and hemimethylation strongly decreased from T1 to T2 in A2. Overall, the DNA methylation events appeared more frequently than demethylation events. This study reports for the first time an accession-/ genotype specific pattern of shift in the DNA methylation under different photoperiodic treatments that will pave the way toward identification of specific genes involved in the regulation of plant response against photoperiodic stress.

P4724Elevated mitral valve pressure gradient is predictive for long-term outcome after percutaneous edge-to-edge mitral valve repair (PMVR) in patients with degenerative MR, but not in functional MR

Background

To analyze the effects of residual mitral regurgitation (MR) and mean mitral valve pressure gradient (MVPG) after percutaneous edge-to-edge mitral valve repair (PMVR) using the MitraClip-system on long term outcome.

Methods and results

Two hundred fifty-five patients who underwent PMVR were analyzed. Kaplan-Meier and Cox regression analyses were performed to evaluate the impact of residual MR and MVPG on clinical outcome. A combined clinical endpoint (all-cause mortality, MV surgery, redo procedure, implantation of a left ventricular assist device) was used.

After PMVR, mean MVPG increased from 1.6±1.0 mmHg to 3.1±1.5 mmHg (p<0.001). Reduction of MR severity to ≤2+ postintervention was achieved in 98.4% of all patients. In the overall patient cohort, residual MR was predictive for the combined endpoint while elevated MVPG >4.4 mmHg was not according to Kaplan-Meier and Cox regression analyses. We then analyzed the cohort with degenerative and that with functional MR separately to account for these different entities.In the cohort with degenerative MR, elevated MVPG was associated with increased occurrence of the primary endpoint, whereas this was not observed in the cohort with functional MR.

Conclusions

MVPG >4.4 mmHg after MitraClip-implantation was predictive for clinical outcome in the patient cohort with degenerative MR. In the patient cohort with functional MR, MVPG >4.4 mmHg was not associated with increased clinical events.

Acknowledgement/Funding

This study was supported by grants from the German Research Foundation (KFO 274), the Volkswagen Foundation (Lichtenberg Program) and the German Heart

Knowledge, Attitudes, and Barriers Toward Research Among Medical Students of Karachi

Introduction

Our study was meant to assess the knowledge, attitude, and barriers towards research in medical students of Pakistan. By assessing the factors, we aim to increase the role of medical students in research, which will eventually help developing countries like Pakistan to achieve self-reliance in health care.

Methods

Undergraduate and postgraduate students of medicine, dentistry, and pharmacy schools of Dow University of Health Sciences, Karachi, were enrolled from February-March 2018 in a cross-sectional, descriptive study using questionnaires to provide details of the parameters of attitude to the knowledge of and barriers towards research for each individual. All data were coded for each of the parameters. Data analyses were performed by one-way analysis of variance (ANOVA)/Tukey and Student’s t-test, Pearson’s correlation, and Chi-squared tests.

Results

A total of 850 questionnaires were received. The overall mean scores of students on attitude, knowledge, and barriers were 69.27 ± 13.44, 70.39 ± 15.67, and 72.46 ± 13.46, respectively; 81.8% of students’ scores fell above the middle of the maximum score for knowledge, but 84.5% of attitude scores came in at below the middle of the maximum score. Undergraduate students had a more positive attitude to research than postgraduate students (69.20 ± 11.10 vs 64.23 ± 10.98; p = 0.002). Male students had a better attitude than females (72.97 ± 20.54 vs 67.09 ± 21.56; p = 0.010). Barriers highlighted by students most significantly included a lack of funding support and preference for instruction over research.

Conclusion

Students showed good knowledge of research, but their attitude was not up to the mark. The barriers highlighted suggest a need for a change in the strategies for research. Attention should be paid to inculcate research as part of the student curriculum and to make available incentives, information, and mentors to solve the problems most students face in the field of research.

Impact of Premature Greying of Hair on Socio-cultural Adjustment and Self-esteem among Medical Undergraduates in Foundation University, Islamabad

Introduction

Greying of hair is an inevitable phenomenon that occurs commonly as a person ages. It usually occurs in the fourth decade regardless of gender but now a days, even people in their early twenties can experience premature greying. The objective of our study was to determine the frequency of premature greying of hair and its impact on the socio-cultural spheres of life and self-esteem of medical students.

Methodology

It is a descriptive cross-sectional study conducted at Foundation University Medical College (FUMC) from January to February 2017. All medical students of FUMC who gave their consent were included in the study sample. Students who were absent or unwilling to participate were excluded. Data was collected through a self-administered questionnaire, which was then analysed using SPSS version 17 (SPSS Inc., Chicago, IL).

Results

Out of 673 students, 210 (31.2%) suffered from premature greying of hair. The prevalence was higher among females (155/73.8%) as compared to males (55/26.2%). There was a statistical difference in perception of both the genders, regarding those with premature greying of hair trying to hide it (p-value = 0.000), premature greying of hair as contagious (p-value = .009) and the affected looking older than their actual age (p-value = 0.036).

Conclusion

The study showed that premature greying affected the socio-cultural spheres of students’ lives. Females were more prone to developing premature greying of hair. Genetics also play a significant role in the phenomenon. No positive correlation was found by using Rosenberg Self-esteem scale.

Anxiety, Depression, and Obsessive-compulsive Disorder in a Recently Diagnosed Case of Systemic Sclerosis

Systemic sclerosis is an autoimmune condition that frequently affects women. It is a progressive, debilitating disease that has widespread manifestations, targeting different organs of the body with potentially fatal consequences due to lung and kidney involvement. Women with this disease mostly present with Raynaud’s phenomenon along with symptoms of gastro-esophageal reflux disease (GERD). Just like any chronic debilitating condition, patients with systemic sclerosis often suffer from mental health issues that can further worsen their condition, significantly affecting their quality of life. Further research regarding the effects and severity of the disease should be encouraged for a better understanding of the illness, its diagnosis, and treatment. We present a rare case of a 55-year-old woman who presented with complaints of a major depressive episode. She was diagnosed with systemic sclerosis last year and has a history of generalized anxiety disorder. She was prescribed Mirtazapine, an antidepressant. On her follow-up after one month, she started complaining of obsessive ruminations that were causing her significant distress. She was prescribed an add-on therapy with a selective serotonin reuptake inhibitor (SSRI) antidepressant with the emphasis being placed on cognitive behavioral therapy (CBT). She reported an improvement in her obsessive symptoms as well as depression after two months.

Case report of Triumeq (abacavir/dolutegravir/lamivudine) associated rhabdomyolysis in a human immunodeficiency virus (HIV) infected patient

RATIONALE

With the existence of the human immunodeficiency virus (HIV) infection as a chronic disease, more often adverse effects of its treatment with the various antiretroviral therapies (ARTs) available have been recognized. Going further, Triumeq has been associated with a myriad of adverse effects, of which rhabdomyolysis is rarely reported in the literature.

PATIENT CONCERNS

The patient presented with muscle tenderness over the lower limbs and dark brown-to-red colored urine.

DIAGNOSIS

Given the presenting symptoms, as well as the laboratory testing, including elevated serum creatine kinase and liver enzymes, the diagnosis of rhabdomyolysis was made.

INTERVENTIONS

Improvement was achieved rapidly after starting intravenous fluid therapy and with discontinuation of Triumeq.

OUTCOMES

After discharge, repeated creatine kinase levels in the clinic have been normal and decision was made to initiate another ART and until now, no further episodes of rhabdomyolysis have developed. Regular outpatient follow-up has been ongoing for over 1 year and no complications have been identified.

LESSONS

This case aims to recognize rhabdomyolysis as a rare, but possible adverse effect associated with the use of Triumeq for HIV-infected patients and therefore clinicians prescribing this combination should be aware of this potential side effect and counsel their patients accordingly.

An update on the CardioMEMS pulmonary artery pressure sensor

Heart failure (HF) is one of the most important healthcare issues due to its prevalence, high morbidity and mortality, as well as its economic burden. A shift in the healthcare model towards reducing inpatient hospitalizations might have a significant impact on HF-related costs and quality of life. Recently, wireless monitoring has begun to be an essential part of the management in the patient with HF. The CardioMEMS HF system is one of the best examples pertaining to the success in this field. This article will discuss the CardioMEMS HF system and the rationale behind its development.

Rarity of Laurence Moon Bardet Biedl Syndrome and its Poor Management in the Pakistani Population

Laurence Moon Bardet Biedl syndrome is characterized as a rare genetic disorder, with a wide range of presenting symptoms such as mental retardation, decreased visual acuity, obesity, hypogonadism, and polydactyly. The diagnosis of this syndrome is easily overlooked due to its rarity, with a prevalence rate of one in 125,000-160,000 reported within Europe. Delayed diagnosis and inappropriate management may lead to an irreversible loss of functions. The most significant of these losses include loss of vision, cardiac problems, and renal abnormalities. These dysfunctions critically impact the mental faculties and personal life of a patient. Our case presented with striking features of this syndrome, but due to a lack of awareness, her family was not adequately counseled. Both the family and the patient were not equipped with the necessary knowledge regarding the nature of her disease and its prognosis. The patient was mismanaged and kept ignorant of the importance of a proper follow-up. This necessitates a multidisciplinary team approach towards such cases so that their disease can be adequately managed. The early diagnosis and symptomatic management of complications as they arise remain the most important and vital step in the management of this illness. We hope that our case sheds further light on the existing knowledge of this syndrome.

Effect of plasma progesterone on oocyte recovery, oocyte quality, and early in-vitro developmental competence of embryos in Bos indicus dairy cows

The objective of present study was to determine the effect of plasma progesterone (P4) on oocyte recovery, oocyte quality, and early in-vitro developmental competence of embryos in Bos indicus dairy cows. The ovaries were collected in an abattoir. These ovaries (n = 750) were divided into two groups: 1) estrous CYCLIC (n = 318), and 2) estrous ACYCLIC (n = 432). Mean serum concentrations of P4 in a subset of (n = 85; 4.21 ± 0.4 ng/ml compared with 0.5 ± 0.2 ng/ml; P <  0.05) were greater in estrous CYCLIC as compared to ACYCLIC cows, respectively. The mean number of oocytes recovered per ovary (6.5 ± 0.5 compared with 4.0 ± 0.2; P <  0.05) was greater for estrous CYCLIC than ACYCLIC cows, respectively. The oocytes with grade I_+_II quality (55.3% compared with 47.6%; P <  0.05) were greater, whereas, there was lesser percentage with grade III_+_IV quality (44.5% compared with 52.4%; P <  0.05) from estrous CYCLIC as compared with ACYCLIC cows, respectively. Cleavage rate (70.9% compared with 52.8%; P < 0.05) was greater for embryos derived from estrous CYCLIC than ACYCLIC cows, respectively. Similarly, the embryo developmental rates to the 8- (38.5% compared with 20.8%; P < 0.05) and 16- (20.0% compared with 10.9%; P < 0.05) cell stage were greater for embryos derived from estrous CYCLIC as compared to ACYCLIC cows, respectively. In conclusion, the presence of greater plasma P4 has a beneficial effect on oocyte recovery, oocyte quality, and early IVEP outcomes in Bos indicus dairy cows.